General medicine

19 YEAR OLD MALE WITH DENGUE 

Thie is an online eblog book to discuss our patients deidentified health data shared after taking his or her guardian signed informed consent.Here we discuss our individual patients problems thorugh series of inputs from avaliable global online commity of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs 

19 yr old male student by occupation came to opd with a complaint of fever

CHEIF COMPLAINTS

Patient was asymptomatic 1 week back
Then he developed high grade fever which was sudden in onset 
Associated with chills and rigors 
Then he developed body pains that was revealed after taking medications 
Weakness
Burning micturation 
No bleeding manifestations are present 
He was taken to local hospital  ,it didnt resolved then he came to our hospital 


HISTORY OF PRESENT ILLNESS 

2 days back he had a platelet count if 1,20000cells/cumm
Then after one day the platelet count raised to 1,30000
Then it decreased, 90000count


HISTORY OF PAST ILLNESS 

No vomitings, loose stools abdominal pain.
History of renal tubular acidosis 8 months back
No history of hypertension 
No history of diabetes 
No history of thyroid, asthama, tuberculosis 
 
PERSONAL HISTORY 

Apatite is normal 
Sleep adequate 
Normal bowel movements 
 Burning micturation 
No known allergies 
No Addictions 

GENERAL EXAMINATION 
Patient is conscious, coherent, cooperative 
No pallor
No clubbing 
No cyanosis 
No edema
No lymphadenopathy 

 VITALS
Temperature 99.5
Bp 90/50mmhg
Respiratory rate14 cycles/min
Spo2 98%
Pulse rate 86bpm


SYSTEMIC EXAMINATION 

CVS 
No thrills
No murmurs 
S1,s2 sounds heard

Respiratory system 
Central position of trachea
No wheeze 
No dyspnoea 
Vesicular breath sounds

Abdomen
No Tenderness 
No palpable mass
Liver and spleen not palpable
Bowel sounds heard

Cvs
Patient is conscious 
Speech is normal
No neck stiffness

PROVISIONAL DIAGNOSIS 

dengue with thrombocytopenia 

Investigations


Treatment :

Iv fluids NS 100 ml/hr
Tab dolo650mg /po
Inj pan 40 mg iv/od
Inj neomol 1gram
Inj zofer4mg/iv



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